Distal Femur Fractures

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Distal Femur Fractures
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Objectives

• Evaluating Understanding the Fracture
• Planning
• Surgery Execution

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Evaluation Understanding the Fracture
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The Patient

• Bimodal age distribution
• young healthy pt, high energy, males
• elderly, osteopenic, low energy, females
• Pre-existing injury/ arthritis
• Amount of energy imparted

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The Problems

• Small articular segments
• Comminution
• Metadiaphyseal
• Articular
• Soft tissue
• Prosthetic issues
• Combinations

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AO/OTA Classification

• 33 Distal femur
• A Extra-articular
• B Intra-articular (single condyle)

• C Intra-articular (both condyles)

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Anatomy Distal Femur

• Physiologic valgus
• (5-9 degrees)
• Mechanical axis
• Posterior half of both femoral condyles lie
  posterior to the femoral shaft

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Anatomy Distal Femur

• Femur transitions from cylinder to condyles
• Medial condyle extends further inferior
• Cancellous bone
• Trapezoidal shape

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What This Means for Fixation

• Avoid notch and concomitant injury to cruciate
  ligaments
• Avoid penetration of medial cortex with anterior
  screws

• X

• X

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Deforming forces

• Quadriceps, hamstrings shorten
• Gastrocnemius extends at fx, rotation of
  intercondylar split
• Other forces from cruciates, capsule, popliteus,
  collateral ligaments

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What This Means for Fixation

• Posterior condyles project POSTERIORLY with
  regard to femoral shaft!

• Dont do
• this!

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Radiographic Exam

• Radiographs
• AP/lateral knee femur
• AP/lateral contralateral distal femur for
  planning
• CT scan-AFTER Ex Fix
• Joint details
• Coronal split
• Sagittal split

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Planning
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External Fixation?

• Spanning knee external fixation
• Allows for temporary stabilization of fracture if
  delayed reconstruction is necessary
• External fixator as a reduction aid at time of
  definitive reconstruction
• Keep pins out of planned surgical field!

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Plan Ahead

• Principles of surgical treatment
• 1. Careful handling of soft tissues
• 2. Anatomic reduction of the articular surface
  and restoration of limb axial alignment,
  rotation, and length
• 3. Indirect reduction techniques
• 4. Stable internal fixation
• 5. Early rehabilitation

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What We Used to Do
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Dual Plate Fixation

• Prevents varus collapse
• Provide medial buttress but at expense of blood
  supply

Dead Bone Sandwich
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" If it is red and alive .... you can kill it
!!! "
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Now
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Internal Fixation Options

• Condylar buttress plates
• Fixed-angle devices
• Blade plate
• Dynamic Condylar Screw (DCS)
• Retrograde intramedullary nail
• Locked plates
• All implants can work if utilized properly!

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Plating

• Advantages
• Direct joint visualization
• Ability to control axial alignment
• Familiarity
• Disadvantages
• Blood loss
• Does not reduce the fracture..you do

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Plan of Attack

• Reduce articular surfaces first
• Direct reduction techniques
• Secure fixation of articular surfaces
• Interfragmentary screws
• Restore continuity of articular block with shaft
• Indirect reduction techniques

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Reduction

• Reduce the Hoffa
• Restore the articular surface
• Reduce the metaphysis to to the diaphysis

• Tip Notice K-wires driven thru medially and out
  of way for plate

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Reduction

• Indirect reduction aids
• Bump
• Ex fix
• Check your lateral for alignment and plate
  position proximally

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Reduction

• First screws distally
• Then secure proximally
• Ensure plate in good position

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Reduction

• Reduction completed before plate applied
• You control the stiffness

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Same Principles for Every Case
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The Injury
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Details (Tiny) After Ex Fix
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The Joint
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Reducing
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Plan Executed
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The End Result
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Indirect Reduction

• Not for articular surfaces
• Direct visualization and reduction
• Preserves soft-tissue envelope around
  metadiaphyseal fracture lines
• Achieve restoration of length, alignment, and
  rotation via traction and manipulation utilizing
  reduction aids that do not strip soft tissues
  around the fracture site

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Indirect Reduction

• Indirect reduction techniques
• External fixator
• Femoral distractor
• Joysticks
• Percutaneous clamps
• Bumps

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Respect the Biology Indirect Reduction

• Limit soft tissue dissection
• Indirect reduction techniques
• Submuscular plate application without extensive
  stripping
• Preserve periosteal blood supply when able

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The Offsides Penalty

• Dont forget to bone graft if necessary

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Retrograde IMN
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Retrograde Nailing

• Has some indications in distal femur fractures
• Must understand the fracture and implant

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Pre-Op Planning

• Radiographic Evaluation
• Knee Films
• Contralateral limb
• Fracture pattern amenable to planned technique
• Devise a plan to determine length and rotation

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When?

• Distal Femur Fractures (Nonarticular)
• Easier Reduction of Distal Fragment
• Obtain Additional Fixation in distal segment
• Screws
• Nail itself
• Avoid Malalignment in coronal and sagital plane

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Extraarticular Distal Femur
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Increased Distal Fixation
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When?

• Distal Femur Fractures (Articular)
• Simpler Articular Fracture
• Extension Proximal
• ORIF Articular Segment
• Nail Between Fixation
• Need enough distal bone to achieve distal
  stability
• Different Device if not possible

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Retrograde IMN

• Dont forget to reduce the fracture first!
• Nail will not assist with this as you are not
  achieving an isthmic fit as can be achieved with
  diaphyseal femoral shaft fractures
• Nail will happily lock a fracture in a
  malreduced position as easily as it will lock a
  fracture reduced

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Retrograde Nailing-Beware!

• Not for complex distal femur fractures!

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Caution!!

• Most Common Deformity is Apex Posterior
• Eccentric Reaming
• Extension Deformity
• May Require Blocking Screws For Salvage

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Retrograde IMN

• Advantages
• Smaller incision
• Percutaneous joint fixation
• Limited exposure
• Decreased blood loss (?)
• Load-sharing device, longer lever arm (if long
  nail utilized)
• Soft tissues intact

• Disadvantages
• Arthrotomy required
• Percutaneous joint fixation
• Lack of alignment control (windshield wipering
  of implant
• Difficulty of insertion with TKA

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Summary
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Avoiding Errors in Judgement

• Make a Problem List
• Soft Tissues
• Hoffa?
• Articular Reduction
• Restoring Metadiaphyseal relationship
• Controlling Stiffness of Implant

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Make A Plan

• Approach
• Plate(s)
• Screws
• Reduction Aids

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Thank You!